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Im a lifelong asthmatic getting worse as I age. And now complicated by the fact I have heart disease since 53. I'm now 55.

Best I can say if I were advocating for myself, and not nicely is, "you are sending me home to die alone of preventable disease in the wealthiest country on Earth and you don't care."
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She should be transferred to the Long Term Care unit of said NH. Also, the number of allowed Medicare days may have run out. I don't know if she has a Medicare Supplement Plan and if so, which "Letter" and whether the NH accepts it.
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Poster has said that she had a meeting with 6 people and SM is being sent home. They have no bed. A nurse will evaluate for homecare.
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Did she come from being admitted to a hospital first?

Depending on her admission diagnosis, medicare usually pays by “groups”. In other words, people who have had similar health issues and how long they were in rehab. They do not go by your stepmom’s personal situation.

For instance, if the majority of people get better and discharged in 45 days, this is what they go by.

The good news is, since she has been in rehab more than 30 days and cannot be discharged under her own care, she can apply for Medicaid and she can stay at the NH facility under medicaid pending. Contact the NH case worker to help you apply. Keep in mind that Medicare stops paying on the day they “discharge” her.

I wish I had known about the Medicaid when my mom went through a similar experience.
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Pattyreddp: So you're saying that they don't have a bed for her in the Long Term Care unit of this same NH? Not so genius idea to send her home. I know Nursing Homes all too well and the way they operate. The one my late mother was in told her that she was too well to stay there. Come again??! Less than 48 hours later she suffered a stroke there and died days later at the hospital.
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When my dad was in rehab with medicaid LTC pending, they kept him in the rehab wing until a LTC bed became available. This woman doesn't have the wherewithall to pay for 24/7 care. Someone must help advocate for her.
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Having worked in LTC, I find this quite bizarre. Once it becomes apparent that the resident is nearing the end of their stay, P.T does a home eval. If the resident is safe to go home then measures are taken to ensure DME equipment, etc., is ordered and set up. If the resident is not safe to go home, and appears to need long term care, then a care plan meeting is set up to help the family with the arrangements, and the resident stays in the rehab wing until a bed becomes available. Furthermore, if they cannot stay at the current facility, then they and the family make arrangements for another LTC facility transfer. A resident CANNOT be discharged to an unsafe environment. I would contact whomever governs LTC facilities in your state....
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ImageIMP Mar 2019
Yup - and, if the "family" is unable or unwilling to participate in the arrangements, the facility and/or Sr Svcs. has to find a safe solution...
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So Patty, is step mom home?
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Pattyreddp Mar 2019
She was home for 6 hours and we had to call 911. She went straight to ICU . I told the nursinh home several times it was an unsafe discharge.
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Patty, thanks so much for coming back. I would call or write to the state ombudsman and file a complaint. Talk to the SW at the hospital about how to prevent this from happening again.
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shad250 Mar 2019
These facilities are protecting themselves first and foremost, as well as trying to prevent having to bill Medicare/Medicaid for care. Facility did not want any issues to happen while she was there, hence the rush to get her discharged and out of their hair.
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Your mother is noncompliant. She needs both a geriatric psych consult along with palliative care. Someone needs to help you and her manage your expectations of what is and is not possible to improve her condition. A rehab facility is not a nursing home although they are often the same facility. If she needs a nursing home placement, now seems like a good time to get that done.
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